HIV Monitoring
Quarterly Report

FIRST QUARTER 2017

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Foreword

As part of the BC Centre for Excellence (BC-CfE) in HIV/AIDS's mandate to evaluate the outcomes of STOP HIV/AIDS programming in BC, we have developed quarterly HIV/AIDS monitoring reports. These reports provide up-to-date data on a variety of key HIV-related surveillance and treatment indicators. Selection of these indicators was achieved through a collaborative process with various Health Authority (HA) representatives. There are six reports in total, one for each HA and one for the province of BC as a whole. In addition, there is a technical report which explains how each HIV indicator is calculated. Data used in these reports come from the British Columbia Centre for Disease Control (BCCDC), MSP billings, hospitalization data from the Discharge Abstract Database, the Sunquest Laboratory database at the Provincial Public Health Microbiology and Reference Laboratory, Providence Health Care laboratory, BC Vital Statistics, and the BC-CfE Drug Treatment Program (DTP) Database.

The objectives of these reports are to:

  1. Provide timely HA-specific information on key HIV indicators which will guide and inform HIV leaders and innovators in the development of future HIV interventions and programs which will ultimately lead to decreasing the burden of HIV in BC. The indicators will reflect ongoing or past successful public health interventions and highlight areas in the HIV care spectrum which require further attention and support.
  2. Highlight limitations in our current data due to incomplete or time lagged data and to develop future strategies to improve complete and timely data capture.

These reports are produced for the benefit of individual HA’s. As such, we are enthusiastic about your involvement and cooperation regarding the development of these monitoring reports. Please forward your comments and queries to Irene Day, Director of Operations at the BC-CFE at iday@cfenet.ubc.ca.

Acknowledgements and Contributions

British Columbia Centre for Excellence in HIV/AIDS (BC-CfE): The BC-CfE is responsible for the conception, preparation and ongoing review of this quarterly report. The BC-CfE provides the data and outputs for Indicators 5 (HIV Cascade of Care), 6 (Programmatic Compliance Score), 7 (New Antiretroviral Starts), 8 (CD4 Cell Count at ART Initiation), 9 (Active and Inactive Drug Treatment Program Participants), 10 (Antiretroviral Adherence Level), 11 (Resistance Testing Results by Resistance Category), 12 (AIDS-Defining Illness), and 13 (HIV-Related Mortality). The BC-CfE database provides pVL and CD4 cell count testing data, as well as ART use. All pVL measurements in BC are performed at the St Paul’s Hospital virology laboratory, thus pVL data capture is 100%. An estimated 80% of all CD4 count measurements performed in the province are captured in the BC-CfE data holdings. The STOP HIV/AIDS Technical Monitoring Committee– BC-CFE is responsible for oversight of the monitoring report. Lilith Swetland is the editor of this report. Paul Sereda, Dr. Viviane Lima and Nada Gataric perform analysis of Indicators 5–13. Rafael Trevisan developed programming for this website. This report was conceived and guided by Dr. Julio Montaner.

British Columbia Centre for Disease Control (BCCDC): The BCCDC provides the data and outputs for Indicator 1 (HIV Testing Episodes), Indicator 2 (HIV Testing Rate), Indicator 3 (New HIV Diagnoses), Indicator 4 (Stage of HIV at Diagnosis) and Indicator 12 (AIDS-Defining Illness). The BCCDC is the single provincial agency that centralizes all HIV surveillance through the Public Health Microbiology and Reference Laboratory, which does more than 90% of all HIV screening tests in BC and all confirmatory testing. Olga Mazo, Theodora Consolacion and Dr. Jason Wong are responsible for outputs for Indicators 1–4

Other Data Sources:

The above databases were supplemented with:

(I) The BC Vital Statistics database which was used to calculate Indicator 5. The HIV Cascade of Care and Indicator 13. HIV-Related Mortality.

(II) Linkage and preparation of the de-identified individual-level database used for calculating Indicator 5. The HIV Cascade of Care was facilitated by the British Columbia Ministry of Health.

(III) The Statistics Canada database: BC and HIV-positive population counts were acquired through the Statistics Canada website to calculate HIV-specific mortality rates for Indicator 13. HIV-Related Mortality.

Membership of the STOP HIV/AIDS Technical
Monitoring Committee–BC-CfE

Dr. Rolando Barrios, Chair, BC-CfE

Dr. Kate Heath, BC-CfE

Dr. Bohdan Nosyk, BC-CfE

Dr. Viviane Dias Lima, BC-CfE

Ms. Irene Day, BC-CfE

Dr. Jean Shoveller, BC-CfE

Dr. Jason Wong, BCCDC

Dr. Mel Krajden, BCCDC

Dr. Robert Parker, FNHA

Mr. Salman Klar, FHA

Ms. Gillian Frosst, IHA

Ms. Kari Harder, NHA

Dr. Neora Pick, PHSA

Dr. Reka Gustafson, VCHA

Dr. Melanie Rusch, VIHA

The Seek and Treat for Optimal Prevention (STOP) HIV/AIDS BC Provincial Program: A Note on Monitoring and Interpreting HIV Indicators

The Seek and Treat for Optimal Prevention (STOP) of HIV/AIDS programme is a provincial initiative to improve HIV diagnosis and care delivery in BC through increased HIV-specific funding to all Health Service Delivery Areas (HSDA’s) across BC. The STOP provincial programme is an expansion of a four-year STOP pilot project which was implemented in two Health Service Delivery Areas in March 2010; the Vancouver HSDA which bears the largest burden of the HIV epidemic in the province and the Northern Interior HSDA which bears a high burden of HIVrelated mortality. The STOP pilot project demonstrated the urgent need for improved efforts in early diagnosis of HIV and timely initiation of antiretroviral therapy (ART) initiation.

The expansion to a province-wide programme was announced on November 30th, 2013 by the BC Ministry of Health with roll out of funding beginning on April 1st, 2013. This funding is intended to be used in the implementation and evaluation of HIV-related diagnosis and care initiatives within individual HA’s. Goals of the project include: 1. A reduction in the number of new HIV infections in BC; 2. Improvements in the quality, effectiveness, and reach of HIV prevention services; 3. An increase in early diagnosis of HIV; 4. A reduction in AIDS cases and HIV-related mortality.

The goals of HA-led STOP-funded initiatives are to work toward achieving these goals. To these ends some outcome measures or indicators of progress have been drafted that should be considered in the design and implementation phases of these initiatives.

HIV Testing Episodes and Rates

In this section, the number of HIV test episodes and point of care (POC) HIV tests conducted each quarter in BC is shown. In general terms the goal is to increase the number of tests performed and to maximize testing efficiency. Test episodes are allocated by region according to where the test is performed.

N.B. All HIV Testing Episodes reflect non-prenatal tests. All prenatal tests have been removed.

New HIV Diagnoses

Trends in HIV diagnoses by gender and exposure category are described. Interpreting HIV diagnoses must be done with consideration that trends are influenced by both changes in testing rate as well as changes in transmission rates. It is important to note that new HIV diagnoses cases and rates are not synonymous with HIV incidence as a person may have become infected with HIV long before they tested positive for HIV. However, as there is no reliable method for measuring HIV incidence, we follow trends in HIV diagnoses.

Stage of HIV Infection at Diagnosis

Classification of stage of HIV infection, in the absence of information regarding recent testing history, is reliant on clinical information available at the time of diagnosis, including first CD4+ cell count and laboratory results suggestive of acute HIV infection (Table 1). The benefits of Treatment as Prevention (TasP) are maximized when antiretroviral therapy (ART) is initiated at high CD4 cell counts. Accordingly, it is preferable that individuals newly diagnosed with HIV be in the early stages of HIV infection (stage 0 or 1) to allow for early ART initiation

N.B. Interpretation of Stage of HIV Infection at Diagnosis should proceed with caution. Early increases in diagnosis at late stage (i.e., low CD4 counts) may represent a "catching up" of previously missed long term infected individuals rather than a trend toward diagnosis at later stage of infection. Additionally, there has been an increase in the proportion of new diagnosis in 2016 for whom these data are missing (37%), leading to a slight overestimation of the overall proportion within each stage.

HIV Cascade of Care

Programmatic Compliance Score

Antiretroviral Uptake

In this section we present trends in ART uptake, the number and proportion of new HIV treatment initiations and the number of active and inactive DTP participants. Trends in ART uptake should be interpreted under the consideration of changing BC HIV treatment guidelines. BC HIV treatment guidelines are updated regularly by the BC-CfE Therapeutic Guidelines Committee and reflect those of the International AIDS Society. Most recent changes were made in 2012 and HIV treatment is now recommended for all HIV-positive adults regardless of CD4 cell count; as evidence demonstrates that early initiation of HIV treatment maximizes both the individual’s health outcomes as well as the potential of ART as a form of HIV transmission prevention at a population level. As such, trends in the number and proportion of persons on ART and new ART starts (in both naïve and experienced persons) are expected to increase over time at higher CD4 cell counts.

Antiretroviral Adherence Level

In this section we present trends in prescription refill adherence levels for individuals in their first year of treatment. Given that the benefits of ART are compromised in the presence of imperfect ART adherence, we expect to see the proportion of persons on ART achieving near perfect adherence (ie. ≥95%) to increase with time. Furthermore, it is important that trends in the proportion of ART users achieving prescription refill adherence of ≥95% keep pace with new ART starts and increase among those continuing on ART

Resistance Testing and Results

AIDS-Defining Illness

HIV-Related Mortality

APPENDICES